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Dukkha was a manifestation of the Mara. He appeared to Tegan Jovanka in a dream. He tempted and tormented her with mind games and thought paradoxes until she agreed to a pact with him. The deal permitted the Mara to take her as a host, allowing it a physical presence in the real world. (TV: Kinda)
Behind the scenes
In Buddhism, one of the three marks of existence is dukkha which roughly translates to "suffering".